Disparities in E-Cigarette and Tobacco Use Among Adolescents With Disabilities

Angela Senders, ND; Willi Horner-Johnson, PhD


Prev Chronic Dis. 2020;17(10):e135 

In This Article

Abstract and Introduction


Introduction: In 2019, nearly 30% of US high-school students reported current (past 30 day) e-cigarette use. Adolescents with disabilities are consistently more likely to smoke cigarettes compared with their nondisabled peers, yet little is known about their use of other forms of tobacco, including e-cigarettes. We compared the prevalence of tobacco use (e-cigarettes, cigarettes, little cigars, large cigars, hookahs, and smokeless tobacco) among high school students with at least 1 disability to those without disability.

Methods: Data were from the 2015 and 2017 Oregon Healthy Teens survey, a statewide representative sample of 11th-grade students. We estimated the prevalence of current (past 30 day) tobacco use by product type and disability status (yes or no). We used multivariable Poisson regression to estimate prevalence ratios measuring the association between disability status and current tobacco use, by product: 1) combustible products only, 2) e-cigarettes only, and 3) dual use of combustibles and e-cigarettes.

Results: Students with disabilities were more likely to use a variety of tobacco products compared with their nondisabled peers, including cigarettes (12.3% vs 5.4%), little cigars (7.0% vs 5.4%), hookahs (6.2% vs 3.8%), and e-cigarettes (18.3% vs 12.3%). In adjusted models, students with a disability were more likely to report using combustibles only (adjusted prevalence ratio [aPR], 1.55; 95% CI, 1.31–1.84), e-cigarettes only (aPR, 1.36; 95% CI, 1.16–1.59), or dual use (aPR, 1.52; 95% CI, 1.29–1.80) compared with nondisabled students.

Conclusion: Effective tobacco control programs should target populations with the greatest burden of tobacco use. Results suggest that tobacco prevention and reduction efforts should explicitly include adolescents with disabilities and employ accommodations that support their participation in program activities.


Adolescent cigarette smoking has declined in recent years, only to be offset by an increase in the use of e-cigarettes and vaping devices (hereinafter referred to as electronic nicotine delivery systems, or ENDS).[1,2] In 2019, 27.5% of high school students reported current (past 30 day) use of ENDS, up from 11.7% in 2017.[2] This surge was partially fueled by the perception among many adolescents that ENDS are fashionable, fun, and safe.[3] Although the understanding of the long-term health effects of ENDS use continue to develop, some clear harms have been documented. Specifically, nicotine can have powerful and lasting effects on the developing brain, and adolescent exposure is associated with impaired cognition, attention, memory, and mood.[4] Adolescents are also susceptible to a strong rewarding effect of nicotine; young smokers are more likely to become addicted than adults, and adolescent exposure to nicotine is associated with subsequent use of other addictive substances.[4] In addition to nicotine, the aerosol from ENDS can contain chemical irritants and carcinogens, including heavy metals, formaldehyde, acetone, ultrafine particulate matter, and polycyclic aromatic hydrocarbons.[4] Use of ENDS has resulted in severe lung damage and in some cases death,[5] and the US Surgeon General has declared ENDS use among young people a major public health concern.[4]

To effectively reduce the use of combustible tobacco products and ENDS, prevention and control efforts should target population groups that bear the greatest burden of tobacco use.[6] Adolescents who report having a disability are consistently more likely to smoke cigarettes compared with their nondisabled peers,[7] and this disparity continues into adulthood.[8] The published evidence of disability-related disparities in tobacco use is primarily limited to cigarettes. Little is known about the full spectrum of tobacco product use among adolescents with disabilities. In particular, we are unaware of any studies that have estimated ENDS use among adolescents in this vulnerable population.

As a population, people with disabilities are subject to health disparities, and efforts to better understand from where preventable health inequalities stem are essential.[9] Therefore, we examined the use of cigarettes, cigars, hookahs, smokeless tobacco, and ENDS in 2015 and 2017 in a statewide representative sample of Oregon 11th-grade students. We compared the age of initiation and the prevalence of current tobacco use in students with self-reported disabilities to those who did not report disabilities.